| Name:
|
| Address:
|
| Social
Sec # |
| Telephone:
|
| Email
address: |
| Position
applied for: |
| Prefer to be Contacted by E-Mail Phone Either |
| Best Time to Call AM PM Anytime |
| How
did you here about our job opportunities? |
| May
we contact you at work? yesno |
| If
you are under 18 and it is required, can you furnish a work
permit? yes no |
| Have
you ever been employed here before? yes no |
| Have
you ever submitted an application here before? yes no
If yes, when |
| Are
you legally eligible for employment in this country? yes
no |
| Date
available for work: |
| What
is your desired salary range or hourly rate of
pay: |
| Type
of employment desired: fulltime
part-time
seasonal
temporary |
| Will
you travel if job requires it? yes no |
| Will
you work overtime if required? yes no |
| Driver's
license number required if driving may be required in the job for
which you are applying:
Driver's lic. #
state
|
| Answering
"yes" to the following question does not constitute an
automatic bar to employment. Factors such as date of the
offense, seriousness and nature of the violation, rehabilitation and
position applied for will be taken into account. |
| Have
you ever been bonded? yes no don't
know |
| Have
you ever pled "guilty" or "no contest" to, or
been convicted of a crime? yes no |
| IF yes, please
provide date(s)
and details:
|
|
|
| Employment
History: Starting with most recent employer, provide the
following information. |
| Employer
name:
Telephone # |
| Street
address:
Starting job title/final job title |
| Dates
employed: start:
to: |
| Compensation:
starting:
ending: hourly
salary |
| Immediate
supervisor and title:
May we contact for reference yes
no |
| Summarize
the type of work and responsibilities: |
| What
did you like the most about your position?: |
| What
did you like least about your position?:
|
|
Why did you
leave?
|
|
Employer
name:
Telephone #
|
| Street
address:
Starting job title/final job title |
| Dates
employed: start:
to: |
| Compensation:
starting:
ending: hourly
salary |
| Immediate
supervisor and title:
May we contact for reference yes
no |
| Summarize
the type of work and responsibilities: |
| What
did you like the most about your position?: |
| What
did you like least about your position?:
|
|
Why did you
leave?
|
|
Employer
name:
Telephone #
|
| Street
address:
Starting job title/final job title |
| Dates
employed: start:
to: |
| Compensation:
starting:
ending: hourly
salary |
| Immediate
supervisor and title:
May we contact for reference yes
no |
| Summarize
the type of work and responsibilities: |
| What
did you like the most about your position?: |
| What
did you like least about your position?:
|
|
Why did you
leave?
|
|
Employer
name:
Telephone #
|
| Street
address:
Starting job title/final job title |
| Dates
employed: start:
to: |
| Compensation:
starting:
ending: hourly
salary |
| Immediate
supervisor and title:
May we contact for reference yes
no |
| Summarize
the type of work and responsibilities: |
| What
did you like the most about your position?: |
| What
did you like least about your position?:
|
|
Why did you
leave?
|
|
Explain any gaps in your employment,
other than those due to illness, injury or disability.
|
| Summarize
any special training, skills, licenses and/or certificates that may
assist you in performing the position for which you are applying
for.
|
|
Educational
Background
|
| School:
Years Completed:
Degree/Certification
attained Other:
|
| School:
Years Completed:
Degree/Certification
attained Other:
|
| School:
Years Completed:
Degree/Certification
attained Other:
|
|
References:
List name and telephone number of three
business/work references who are not related to you and are not
previous supervisors. If not applicable, list three school or
personal references who are not related to you.
Name:
Title:
Relationship to you
Telephone:
# of years known
|
|
Name:
Title:
Relationship to you
Telephone:
# of years known
|
|
Name:
Title:
Relationship to you
Telephone:
# of years known
|
| List
special accomplishments, publications, awards, etc. (exclude
information that would reveal race, religion, sex, national origin,
citizenship, age, mental or physical disabilities, veteran/reserve
national guard or any other similarly protected status)
|
| In
your current or a prior job, have you ever written instructions or
directions to be followed by employees or customer? yes
no
If yes, please explain.
|
| Is there any other job-related
information you want us to know about you?
Applicant Statement:
I certify that all information I have
provided in order to apply for and secure work with this employer is
true, complete and correct.
I expressly authorize, without
reservation, the employer, its representative, employees or agents
to contact and obtain information from all references (personal and professional),
employers, public agencies, licensing authorities and educational
institutions and to otherwise verify the accuracy of all information
provided by me in this application, resume or job interview. I
herby waive any and all rights and claims I may have regarding the employer,
its agents, employees or representative, for seeking, gathering and
using truthful and non-defamatory information, in a lawful manner,
in the employment process and all other persons, corporations or
organizations for furnishing such information about me.
I understand that this employer does
not unlawfully discriminate in employment and no question on this
application is used for the purpose of limiting or eliminating any
applicant from consideration for employment on any basis prohibited
by applicable local, state or federal law.
I understand that this application
remains current for only 30 days. At the conclusion of that
time, if i have not heard from the employer and still wish to be
considered for employment, it will be necessary for me to reapply
and fill out a new application.
If I am hired, I understand that I am
free to resign at any time with or without cause and with or without
prior notice, and the employer reserves the same right to terminate
my employment at any time, with or without cause and with or without
prior notice, except as may be required by law. This
application does not constitute an agreement or contract for
employment for any specified period or definite duration. I
understand that no supervisor or representative of the employer is
authorized to make any assurances to the contrary and that no
implied oral or written agreements contrary to the foregoing express
language are valid unless they are in writing and signed by the
employer's president.
I also understand that if I am hired,
I will be required to provide proof of identity and legal
authorization to work in the United States and that federal
immigration laws require me to complete and I-9 Form in this
regard.
I understand that any information
provided by me that is found to be false, incomplete or
misrepresented in any respect, will be sufficient cause to (i)
eliminate me from further consideration for employment, or (ii) may
result in my immediate discharge from the employer's service,
whenever it is discovered.
DO NOT SIGN UNTIL YOU HAVE READ
THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully
understand and accept all terms of the foregoing Applicant Statement
Signature
of Applicant:
Date:
|